Vascular Access for Haemodialysis

Mike Stephens

Overview

• Learning Objectives

• History and development of vascular access

• Standards in vascular access surgery

• Types of vascular access

• Complications

Objectives of the Session

• Understand the different types of vascular access available for

haemodialysis patients

• Know how to assess a patient for vascular access surgery

• Know how to consent a patient for vascular access procedures

Development of Vascular Access Surgery

1657 Sir Christopher Wren invented an instrument for IV injections

1665 Lower reported the first transfusion between dogs

1667 Jean Denys performed the first successful transfusion into humans

1818 James Blundell performed the first trabsfusion of human blood

1901 Karl Landsteiner discovered ABO blood groups

1914 Richard Lewisohn introduced sodium citrate as anticoagulant

1937 Landsteiner and Weiner discovered the Rh factor

1913 Abel, Rowntree and Turner created an artificial kidney

1943 Kolff developed the first practical model for humans

1955 Kolff revised model (including 7 beer cans and a fruit juice can)

1960 Scribner, Dillard, Quinton devised a Teflon-Silastic AV shunt

1966 Brescia, Cimino, Appel and Hurwich described a subcutaneous AVF

1973 Indwelling right atrial catheter developed for TPN

1979 Hickman and colleagues reported their modification

1984 Bothe and colleagues described their Port-a-Cath

“…promptly jumped down from the table, and

apparently oblivious of its hurts, soon began to

fondle its master…..”

Lower, 1665

Development of Vascular Access Surgery

1657 Sir Christopher Wren invented an instrument for IV injections

1665 Lower reported the first transfusion between dogs

1667 Jean Denys performed the first successful transfusion into humans

1818 James Blundell performed the first trabsfusion of human blood

1901 Karl Landsteiner discovered ABO blood groups

1914 Richard Lewisohn introduced sodium citrate as anticoagulant

1937 Landsteiner and Weiner discovered the Rh factor

1913 Abel, Rowntree and Turner created an artificial kidney

1943 Kolff developed the first practical model for humans

1955 Kolff revised model (including 7 beer cans and a fruit juice can)

1960 Scribner, Dillard, Quinton devised a Teflon-Silastic AV shunt

1966 Brescia, Cimino, Appel and Hurwich described a subcutaneous AVF

1973 Indwelling right atrial catheter developed for TPN

1979 Hickman and colleagues reported their modification

1984 Bothe and colleagues described their Port-a-Cath

Development of Vascular Access Surgery

1657 Sir Christopher Wren invented an instrument for IV injections

1665 Lower reported the first transfusion between dogs

1667 Jean Denys performed the first successful transfusion into humans

1818 James Blundell performed the first trabsfusion of human blood

1901 Karl Landsteiner discovered ABO blood groups

1914 Richard Lewisohn introduced sodium citrate as anticoagulant

1937 Landsteiner and Weiner discovered the Rh factor

1913 Abel, Rowntree and Turner created an artificial kidney

1943 Kolff developed the first practical model for humans

1955 Kolff revised model (including 7 beer cans and a fruit juice can)

1960 Scribner, Dillard, Quinton devised a Teflon-Silastic AV shunt

1966 Brescia, Cimino, Appel and Hurwich described a subcutaneous AVF

1973 Indwelling right atrial catheter developed for TPN

1979 Hickman and colleagues reported their modification

1984 Bothe and colleagues described their Port-a-Cath

The Ideal Vascular Access

• Provide safe and effective therapy by enabling the

removal and return of blood via an extracorporeal circuit

• Easy to use

• Reliable

• Minimal risk to the individual

Options

Options

• Arteriovenous fistula

• Arteriovenous graft

• Tunnelled venous catheter

• Non-tunnelled venous catheter

UK Renal Association Guidelines

• 65% of incident HD patients should commence dialysis

with an AV fistula

• 85% of prevalent HD patients should receive dialysis via

a functioning fistula

Clinical Practice Guidelines 2011

Incident patients Cardiff

%

2010/11 2011/120

10

20

30

40

50

60

70

80

90

100

Audit Target

65%

2012/13 2013/14

Prevalent patients Cardiff

%

2010/11 2011/120

10

20

30

40

50

60

70

80

90

100

2012/13 2013/14

Audit Target

85%

When to start planning for Vascular Access

When to start planning for Vascular Access

• When patients enter CKD stage 4

• Exact timing of placement will depend on rate of decline,

co-morbidities, transplant options and type of access

planned

Fistulogram

Transplant assessment required

Transplant assessment not required

Double OPA with prior duplex Date for surgery Pre-op assessment

One stop access clinic Date for surgery Pre-op assessment

Surgery 1 week post-op OPD review

Prevalent dialysis patient

with fistula problem

4 weeks post-op Doppler USS

Mature

Needle fistula

Discharge

Not Maturing

Review by access

surgeon

Fistulogram Re-do

surgery

Referral to Access Co-

ordinator

CKD patient with declining eGFR<20 (<25 with DM) or likely to require dialysis in

the next 6 months

‘Crash

Lander’

Vascular Access Clinic

Vascular Access Clinic

• General Health (DM/CVD/PVD)

• Medication history (anticoagulants/antiplatelets)

• Occupation

• Dominant Arm

• Superficial veins

• Allen’s test

• Doppler Ultrasound Scan

• Date for Surgery

• Pre-operative Assessment

Options for AV fistulae

Options for AV fistulae

• Snuff-box fistula

• Radiocephalic fistula (wrist or forearm)

• Brachiocubital fistula

• Brachiocephalic fistula

• Brachiobasilic fistula

• Saphenous vein fistula

AV graft options

• Forearm straight graft

• Forearm loop graft

• Brachio-axillary graft

• Femoro-saphenous loop graft

• Femero-femoral loop graft

• Axillo-axillary graft

Assessing maturation

• Clinical

• Doppler Ultrasound

Flow >600ml/min

Cannulation segment >10cm long or two 4cm segments

Outflow vein diameter >6mm

Cannulation segment <6mm from skin surface

Complications of Vascular Access

Thrombosis

• 1 year patency AVFs approx. 65%

• Many factors

small vessels

dehydration

hypotension

venous outflow obstruction

• Primary patency at 2 years:-

AVF 43% AVG 31%

• Secondary patency at 2 years:-

AVF 64% AVG 60%

High Output Heart Failure

• Rapid flow changes immediately after construction

RC AVF 250ml/min

BC AVF 600ml/min

• Heart Failure relatively uncommon (surprisingly)

• Probably need 25%-50% cardiac output through fistula

to result in failure

• Revision possible

Venous Hypertension

• Rapid if central stenosis

• May be due to retrograde flow

• Treatment depends on exact cause

May get better

May need to ligate fistula

Consider venogram

Aneurysms

• Pseudo-aneurysms

Needling sites

Infection

• True aneurysms

If skin threatened may bleed

Management depends on size/symptoms/skin

Ischaemic Steal Syndrome

• Prevalence 10-20% (symptomatic), 4% requiring intervention

• More likely and more rapid with AVG

• Diagnosis clinical plus Doppler assessment

• Difficult to predict

• Operative treatments:-

Ligation

Banding

DRIL

RUDI

Neuropathy

• Carpal tunnel syndrome-like symptoms

• Ischaemic Monomelic Neuropathy (Vascular Access

Neuropathic Syndrome)

Summary

• Vascular Access takes careful planning

• High failure rates but successful outcomes achievable

• Complications are common but usually manageable